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Pace2
Benefit
Summary
2015
Better living. Better life.
Pace2
You are an established family in need
of extensive day-to-day cover with
freedom of choice when it comes to
hospitals, doctors and specialists. You
also require extensive out of hospital
benefits and the assurance that comes
with a full-range of chronic benefit
cover. Enjoy peace of mind in that
Pace2 will take great care of you and
your family’s healthcare needs.
Method of Scheme
Benefit Payment
On the Pace2 option in-hospital services are paid from Scheme risk. Some
out-of-hospital services are paid from your annual savings first and once
depleted will be paid from Scheme risk. Preventative care available from
Scheme risk.
Please take note that day-to-day expenses are covered from savings first,
thereafter from limited Scheme risk benefits.
We are a Scheme
managed by
members for
members and will
never compromise
on quality service
to you.
In-Hospital Benefits
Note:
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All in-hospital benefits referred to in the section below require
pre-authorisation. Please contact 0800 22 0106 to obtain a
pre-authorisation number.
Clinical funding protocols, preferred providers, designated service
providers (DSPs), formularies, funding guidelines and the Mediscor
Reference Price (MRP) may apply.
MEDICAL EVENT
SCHEME BENEFIT
Accommodation (hospital
stay) and theatre fees
100% Scheme tariff.
Take-home medicine
100% Scheme tariff.
Limited to 7 days’ medicine.
Treatment in mental
health clinics
100% Scheme tariff.
Treatment of chemical
and substance abuse
100% Scheme tariff.
Consultations and procedures
100% Scheme tariff.
Surgical procedures
and anaesthetics
100% Scheme tariff.
Organ transplants
100% Scheme tariff. (Only PMBs)
Dentistry: Maxillo-facial
surgery strictly related to
certain conditions
100% Scheme tariff.
Prosthesis
(Subject to preferred
provider, otherwise limits
and co-payments apply)
100% Scheme tariff.
Prosthesis – Internal
Sub-limits per beneficiary:
Limited to 21 days per beneficiary.
Limited to 21 days or R21 500
per beneficiary.
Limited to R83 600 per family.
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Pacemaker (dual chamber) R43 100
Vascular R29 900
Spinal R29 900
Artificial disk R13 100
Drug-eluting stents R13 100
Mesh R13 100
Gynaecology/Urology R9 800
Lens implants R8 400 per lens
Joint Replacements:
−− Hip replacement and other major
joints R35 900
−− Knee replacement R41 700
−− Minor joints R15 500
Prosthesis – External
Limited to R19 700 per family.
Orthopaedic and
medical appliances
100% Scheme tariff.
In-Hospital Benefits
MEDICAL EVENT
SCHEME BENEFIT
Pathology
100% Scheme tariff.
Diagnostic imaging
100% Scheme tariff.
Specialised
diagnostic imaging
100% Scheme tariff.
Oncology
Oncology Programme.
100% Scheme tariff.
Peritoneal Dialysis
and Haemodialysis
100% Scheme tariff.
Confinements
100% Scheme tariff.
Midwife-assisted births
100% Scheme tariff.
Supplementary services
100% Scheme tariff.
Alternatives to
hospitalisation
100% Scheme tariff.
Emergency evacuation
100% Scheme tariff. Pre-authorised
and rendered by ER24.
Did you know that
you can make your
benefits last longer?
Simply ask your
doctor to prescribe
generic medicines
where possible.
Out-of-Hospital Benefits
Note:
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Some indicated benefits are paid from the annual savings at 100%
Scheme tariff.
Once the annual savings account is depleted, benefits will be paid from
the Scheme risk (limits apply).
Should you not use all of the funds available in your medical savings
account, these funds will be transferred into a Vested Medical Savings
Account at the beginning of the following financial year.
Any vested credit in your Vested Medical Savings Account may be used
for out-of-hospital expenses that are not covered by the Scheme, or
should you, for instance, have reached your out-of-hospital/day-to-day
overall annual limit or the sub-limits as indicated in your benefit guide.
Unused funds in your Vested Medical Savings Account at the end of the
financial year will be carried over to the credit of your Vested Medical
Savings Account for the next year.
Clinical funding protocols, preferred providers, designated service
providers (DSPs), formularies, funding guidelines and the Mediscor
Reference Price (MRP) may apply.
MEDICAL EVENT
SCHEME BENEFIT
Day-to-day benefits
M = R11 400, M1+ = R23 400.
GP and Specialist consultations
Limited to M = R3 200, M1+ = R6 400.
(Subject to day-to-day overall limit)
Basic and specialised dentistry
Orthodontics are subject to
pre-authorisation. Limited to
M = R4 900, M1+ = R9 900.
(Subject to day-to-day overall limit)
Medical aids, apparatus
and appliances
100% Scheme tariff. Limited to R7 500
per family. Limit on wheelchairs of
R10 200 per family per 48 months.
Limit on hearing aids R20 800 per
beneficiary per 24 months.
Supplementary services
Limited to M = R4 000, M1+ = R8 000.
(Subject to day-to-day overall limit)
Wound care benefit
(incl. dressings and negative
pressure wound therapy (NPWT)
treatment and related nursing
services - out of hospital)
100% Scheme tariff.
Limited to R5 000 per family.
Out-of-Hospital Benefits
MEDICAL EVENT
SCHEME BENEFIT
Optometry services
(PPN Capitation provider)
Optometry services are obtained
from and paid by PPN at 100% of cost
per beneficiary every 24 months.*
For services rendered by a
non-network provider, the following
maximum amounts per beneficiary
apply every 24 months:
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Consultation R310
Frame R500 AND
−− Single-vision lenses R150 OR
−− Bifocal lenses R325 OR
−− Multifocal lenses R600 OR
Contact lenses R1 210**
Diagnostic imaging
and Pathology
Limited to M = R2 400, M1+ = R4 800.
Specialised diagnostic imaging
100% Scheme tariff.
(Subject to day-to-day overall limit)
Subject to pre-authorisation.
MRI/CT scans: Maximum of three
scans per beneficiary.
PET scan: One scan per beneficiary.
Oncology
Oncology Programme.
100% Scheme tariff.
Subject to pre-authorisation.
Peritoneal Dialysis
and Haemodialysis
100% Scheme tariff.
Maternity benefits
100% Scheme tariff. 2 sonars and
up to 12 antenatal consultations.
Rehabilitation services
after trauma
100% Scheme tariff.
Subject to pre-authorisation.
*This means that there will be no co-payment but limited to only those products and
services negotiated by PPN and only those frames specified by PPN.
**Preferred Provider Negotiators (PPN) will pay a maximum amount of R1 210 towards
the cost for contact lenses per beneficiary every 24 (twenty-four) months, irrespective of
whether the beneficiary utilised the services of PPN or a non–network provider.
We always
strive to
exceed your
expectations.
With us you get the
best when it comes
to accessing quality
healthcare.
Medicine
Note:
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All benefits below may be subject to pre-authorisation, clinical
protocols, formularies, funding guidelines and the Mediscor Reference
Price (MRP).
For a list of all chronic conditions, please refer to our website at
www.bestmed.co.za
*Please note that CDL and non-CDL chronic medicine costs will be paid from the non-CDL limit first. Thereafter, CDL chronic medicine costs continue being paid by the Scheme.
BENEFIT DESCRIPTION
SCHEME BENEFIT
CDL chronic medicine*
100% Scheme tariff. Co-payment of
30% for non-formulary medicine.
Non-CDL chronic medicine*
31 conditions. 85% Scheme tariff.
Limited to M = R8 700,
M1+ = R17 400. Co-payment of 30%
for non-formulary medicine.
Biologicals and other
high-cost medicine
100% Scheme tariff.
Acute medicine
Savings first.
Limited to R119 900 per beneficiary.
Limited to M = R3 700, M1 + = R7 400.
(Subject to day-to-day overall limit)
Over-the-counter
(OTC) medicine
Limited to R1 200 per family.
(Subject to day-to-day overall limit)
Preventative Care Benefits
Note: Benefits mentioned below may be subject to pre-authorisation,
clinical protocols, formularies, funding guidelines and the Mediscor
Reference Price (MRP).
PREVENTATIVE CARE BENEFIT
GENDER AND AGE GROUP
Flu vaccines
All ages.
Pneumonia vaccines
Children < 2 years.
High-risk adult group.
Paediatric immunisations
Babies and children.
Female contraceptives
All females of child-bearing age.
Back rehabilitation programme
All ages.
Provided by Documentation
Based Care (DBC)
HIB titre immunisation
Children 5 years and younger.
Mammogram
Females 40 years and older.
PAP smear
Females 40 years and older.
PSA test
Males 45 years and older.
HPV vaccinations
Females of 9-26 years old.
Biometric screening:
All beneficiaries, 10 years and older.
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Glucose test (finger-prick test)
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Cholesterol test (finger-prick test)
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Blood Pressure
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Body Mass Index (BMI)
Dietician counselling session
All ages.
QUANTITY AND FREQUENCY
BENEFIT CRITERIA
1 per beneficiary per year.
Applicable to all active members
and beneficiaries.
Once every 60 months.
Funding for adults:
The Scheme will identify certain
high-risk individuals who will be
advised to be immunised.
Funding for all paediatric vaccines according to the
state-recommended programme.
Quantity and frequency
depending on product up to
the maximum allowed amount.
Mirena device - 1 device every
60 months.
Limited to R1 500 per family per year.
Includes all items classified in the
category of female contraceptives.
Up to 6 weeks treatment plan
as per approval.
Applicable to beneficiaries who have
serious spinal or back problems and
may require surgery. The Scheme
identifies appropriate participants for
evaluation at the DBC Centre. Based
on the outcomes of the evaluation,
a rehabilitation treatment plan is
drawn up and initiated which lasts
approximately 6 weeks.
1 vaccine at 6, 10 and 14 weeks
after birth.
1 booster vaccine between
15-18 months.
If the booster vaccine was not
administered timeously, the
maximum age to which it will be
allowed is 5 years.
Once every 24 months.
Scheme tariff is applicable.
Once per year.
Can be done at a gynaecologist
or GP. Consultation paid from the
consultation benefit.
Once per year.
To be done at urologist. Urologist
consultation paid from the
consultation benefit.
3 vaccinations per beneficiary.
Vaccinations will be funded at MRP.
1 per beneficiary per year.
All beneficiaries, 10 years and older,
have access to 1 biometric benefit
package from selected pharmacies
(Dis-Chem, Clicks, Script Savers and
Pick n Pay).
1 per family per year.
Educational.
BestBaby Programme
With so many things to juggle, the BestBaby programme is created to help
moms and dads through the entire pregnancy without missing a beat.
At Bestmed we want you to enjoy this entire experience.
Registering on this programme will give you the following support
and benefits:
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A 24-hour professional medical advice line.
Weekly e-mails packed with convenient information about your
pregnancy, your baby’s development, how to deal with unpleasant
pregnancy symptoms and useful tips.
Dads won’t be left out as they will also receive e-mails every second week
to inform them about the baby’s development and Mom’s progress.
To make sure your pregnancy starts right you will receive a welcome
pack containing an informative pregnancy book to guide you through the
stages and discount vouchers for various baby items. Mom and Dad can
also expect a pregnancy health pack, via Fastmail, within the first month
of registration.
In your second month after registration, we will send you a beautiful baby
bag, to your door, packed with products to use after baby’s birth. Momsto-be can expect their bag to contain wonderful products.
* Please note that you may only register in the programme after 12 weeks of pregnancy.
Midwife-assisted
births are covered
at 100% of
Scheme tariff on
all Pace options.
For a more detailed
overview of your
benefit option and to
receive a membership
guide please contact
service@bestmed.co.za
Preventative Dentistry
Note: Services mentioned below may be subject to pre-authorisation,
clinical protocols, formularies, funding guidelines and the Mediscor
Reference Price (MRP).
DESCRIPTION
OF SERVICE
AGE
FREQUENCY
General full-mouth
examination by a general
dentist (incl. gloves and
use of sterile equipment
for this visit)
Above 12 years.
Once a year.
Under 12 years.
Twice a year.
Full-mouth
intra-oral radiographs
All ages.
Once every
36 months.
Intra-oral radiograph
All ages.
2 x photos per year.
Scaling and/or polishing
All ages.
Twice a year.
Fluoride treatment
All ages.
Twice a year.
Fissure sealing
Up to and including
21 years.
In accordance with
accepted protocol.
Space maintainers
During primary
and mixed
denture stage.
Once per space.
Disclaimer on exclusions: General and option-specific exclusions apply.
Please refer to www.bestmed.co.za for more detail.
Contributions
PRINCIPAL
MEMBER
Risk amount
ADULT
DEPENDANT
CHILD
DEPENDANT*
R3 000
R2 940
R661
R529
R519
R117
Total monthly
contribution
R3 529
R3 459
R778
Annual savings
account
R6 348
R6 228
R1 404
Savings amount
* You only pay for a maximum of four children.
All other children can join as beneficiaries of the Scheme free of charge.
You can save money
by obtaining preauthorisation for
planned, in-hospital
medical procedures
in advance.
Abbreviations
CDL = Chronic Disease List; DBC = Documentation Based Care (back rehabilitation
programme); GP = General Practitioner or Doctor; HPV = Human Papilloma Virus;
M = Member; M1+ = Member and family; MRP = Mediscor Reference Price;
MRI/CT Scans = Magnetic Resonance Imaging/Computed Tomography Scans;
NPWT = Negative Pressure Wound Therapy; PET scan = Positron Emission Tomography
scan; PPN = Preferred Provider Negotiators; PSA = Prostate Specific Antigen.
For a more detailed overview of your benefit option and to receive a membership guide please contact
service@bestmed.co.za
Disclaimer: Whilst Bestmed has taken all reasonable care in compiling this membership guide, we cannot
accept liability for any errors or omissions contained herein. Please note that should a dispute arise, the
registered Rules of Bestmed as approved by the Registrar of Medical Schemes shall prevail.
Please visit www.bestmed.co.za for the complete liability and responsibility disclaimer for Bestmed
Medical Scheme as well as our terms and conditions.
©Bestmed Medical Scheme 2014
Bestmed Medical Scheme is a registered medical scheme (Reg. no. 1252) and an Authorised Financial
Services Provider (FSP no. 44058).
705058 Bestmed Pace2 Benefit Summary 03/03/2015 This brochure was printed in March 2015.
For the most recent version please visit our website at www.bestmed.co.za
Contact Details
SMS
‘QUOTE’ to
41631
086 000 2378
and we’ll call
you back
service@bestmed.co.za
012 472 6500
www.bestmed.co.za
@BestmedSocial
www.facebook.com/
BestmedMedicalScheme
WALK-IN FACILITY
Block A, Glenfield Office Park, 361 Oberon Avenue, Faerie Glen, Pretoria, 0081
POSTAL ADDRESS
P. O. Box 2297, Arcadia, Pretoria, 0001, South Africa
ER24 AND INTERNATIONAL TRAVEL COVER
Tel:
084 124
HOSPITAL AUTHORISATION
Tel:
0800 22 0106
E-mail: authorisations@bestmed.co.za
CHRONIC MEDICINE
Tel:
086 000 2378
E-mail: medicine@bestmed.co.za
Fax: 012 472 6760
ENQUIRIES AND CLAIMS
Tel:
E-mail:
086 000 2378
service@bestmed.co.za (queries)
claims@bestmed.co.za (claim submissions)
BESTBABY
Register by phoning 0861 111 936 or e-mail your medical aid number
to info@babyhealth.co.za
BESTMED HOTLINE, OPERATED BY KPMG
Should you be aware of any fraudulent, corrupt or unethical practices involving
Bestmed members, service providers or employees, please report this
anonymously to KPMG.
Hotline:
Hotfax:
Hotmail:
Postal: 0801 11 02 10 toll-free from any Telkom line
0800 200 796
fraud@kpmg.co.za
KPMG Hotpost, at BNT 371
P. O. Box 14671, Sinoville, 0129